Documentation supports the same condition in both eyes, and ICD-10-CM offers a bilateral code for that condition. What is the correct laterality approach?
Select an answer to reveal the explanation.
Short Explanation
Laterality is basically “which side?” If the codebook already baked in a bilateral option, use that tidy one-code solution. No bilateral code? Then you may need a code for each side the record actually supports.
Full Explanation
ICD-10-CM laterality conventions require use of a bilateral code when the classification provides one and documentation supports bilateral involvement. When a bilateral code is not available, each affected side is coded separately as supported by the record. Coders should not invent dual unilateral coding when a bilateral code already captures the condition.